Aging in Place — Family and Community Support & Care

Research Background

Hong Kong is confronted with the big challenges of aging population. Despite medical advancement, 22.8% of the elderly people are unable to perform at least one item of instrumental activities in daily living*. Family members are their main carers; however, 52.4% of the older persons do not have their care needs met.

Aging in Place

The principle of ‘aging in place’ means that the elderly people are able to age at home and live in familiar community until their health deteriorates to the level where residential care services are required. Aging in place has the advantages of preserving their health and quality of life, and, in fact, this is exactly what the elderly (96.4%) have desired according to government survey findings. However, the institutionalization rate in Hong Kong is relatively high in Hong Kong (6.8%), which is double and even four times the rate in Japan, Singapore, Taiwan or the Mainland. According to international experience, this indicates deficiencies in our system of aging in place.

Support to Family Carers and its Problems
Despite the process of rapid modernization, filial piety remains a strong value in Hong Kong society. A high proportion of adults are ‘grateful to parents for raising them’ and agree to ‘support parents to make them more comfortable’. Thus nearly 40% of family carers for the elderly are their children.

However, local family carers are confronted with a number of structural constraints. Firstly, long working hours impose time pressure on them. Secondly, only 37.5% of children live with their parents, and even less (15.1%) live within walking distance from where their parents live.

Thirdly, the caring relationship increases the carers’ monthly expenses, and their incomes probably also decrease, especially in the case of full-time carers. Fourthly, with the trend of smaller-sized families, all of the above constraints are made even more substantial.

All these pressures have adverse impact on the carers and their families, including their physical and mental health. In addition, when they find it hard to juggle work with family duties, the care for their elderly parents may be compromised. In fact, there is enough evidence to show that family carers can easily burn themselves out if the pressures are not assuaged. The consequence is institutionalization against the principle of, and the desire of their parents to, age in place.

At present, there are three kinds of social support to family carers, and each has its own problems. Firstly, subsidized social service organizations run programmes to provide information, training, self-help groups and counselling for the carers. However, the accessibility of these programmes is low. Only 8.8% of carers have ever attended any of the programmes, and 11.6% have never been aware of their existence. Secondly, the HKSAR Government, through the Community Care Fund, provides financial support to the carers. There are many restrictions to the financial aid, though, and the most controversial is that the carers already on Comprehensive Social Security Assistance or Old Age Living Allowance schemes are ruled out. However, this criterion undermines the symbolic meaning of the financial support, which is seen as a tribute to carers who give up jobs and sacrifice their personal lives in order to take good care of their elderly parents. Thirdly, day respite services are provided by subsidized day care centres.

Deficiencies in Community Care Services

Family carers are central to elderly care. But the fact is that half of the elderly care needs cannot be met in the family. It is therefore important to review the existing system of community care, which comprises centre-based care and home care. There is a range of problems.

Shortage and Imbalance of Government Funding
The principle of aging in place is not exemplified in resource allocation. In 2014-15, for example, the amount that the government invested in residential care is HK$ 3.9 billion, which is 3.5 times the amount spent in community care. The service quotas in residential care are, as a result, 2.7 times the quotas in community care.

Shortage of Service Places
Lack of service places and long waiting time are common to all community care services. On average, the elderly (frail cases) have to wait 10 months before home care or centre-based care service is available. Likewise, the day respite services are clearly in shortage. Since opportune intervention is central to aging in place, the waiting time of 10 months is undesirable.

Inflexible Services
Under the existing schemes of day care, there is no meal delivery on Sundays and public holidays. To accommodate the huge demand on and working hours of frontline staff, meals are delivered way before meal time. The same rigidity is seen in day care centres, with their opening hours restricted to 8 a.m. – 6 p.m., and services are not provided on Sundays.

Lack of Personalized Services
Local community care services focus on basic care. Owing to the shortage of frontline staff, the social, emotional and psychological needs of the elderly are often compromised. According to a survey, the elderly person usually spends 19 hours alone in daily routine, but to have someone in company is surely what they would have desired.

Policy Recommendations

Because of the deficiencies mentioned above, only 57.8% of the elderly feel satisfied with the community care services they have. Low satisfaction undermines their confidence in aging in place. Therefore, we have the following recommendations:

Recommendation 1: Regularize the Financial Aid to Family Carers

To balance between the symbolic meaning of the aid and its possible abuse, it is recommended to adopt a regressive aid system. In other words, given that the income of a carer does not exceed the upper limit (75% of median household income at present), the carer will be eligible for the aid, even though he/she is on the Comprehensive Social Security Assistance or Old Age Living Allowance. However, the aid to be received by the carer will be reduced in proportion to the amount of other aids already provided. With the possible abuse being avoided, the Government should regularize the aid and consider increasing its amount.

Recommendation 2: Strengthen the Accessibility of the Aid to Carers

A low proportion of carers are aware of and have attended community support programmes. Even if they were aware, they might not have the knowledge to judge which support was desirable. It is proposed that the Social Welfare Department may invite the family members (especially the main carers) of the aged who were and are currently on the Central Waiting List for Subsidized Long Term Care Services, to participate in need assessment exercises conducted by social workers. Needs will be identified and reference will be made to the relevant community support programmes. In the longer term, the government may take reference of the Care Act (2014) in UK and establish equal rights for the carers by legislation.

Recommendation 3: Protect the rights of Family Carers

The carers with employment commonly face outstanding time pressure. In this regard, the Government may take reference of the Employment Rights Act enacted by the UK government in 1996. According to the law, the carers have the right to request flexible working (e.g. home working, working compressed hours and flexi-time) after they have worked for the same employer for 26 weeks. The key to flexible working is not that the employers must make corresponding arrangements; instead, the carers have the right to bring up the issue and the request may be rejected on reasonable grounds. By the same token, the carers have the right to request unpaid time off work to deal with an emergency or an unforeseen matter involving their aged parents.

Recommendation 4: Plan for the Service Quotas and Enhance Quality

Increase the Rates of Service Places
Based on the data of 2014-15, which cover the rate of service places available (per 1,000 elderly persons) and the rate of shortage, we propose that the Government have to combine the two sets of figures and increase the service quotas. Specifically, the Government has to work towards the provision of 8.77 places (per 1,000 elderly persons) in home care and 5.73 places (per 1,000 elderly persons) in day care centres.

Increase the Service Quotas and Funding
To put the recommended rates of service places into practice, by 2019-20 the Government has to provide 3,003 and 2,488 extra places in home care and day care centres respectively, in addition to what was already provided in 2014-15. In terms of financing the extra service quotas, the Government has to earmark HK$ 540 millions of additional funds by the year of 2019-20.

Enhance the Quality of Care
In order to achieve quality care, measures should be taken to: 1) extend the service hours to evenings and to cover Sundays and possibly public holidays, which would enable the family carers (especially those in the service sector) to balance work and family duties; 2) increase the number of times where the aged are helped with household cleaning and rehabilitation; 3) add new services like home repair, Chinese medicine treatment and ad hoc escort service for medical appointment on the service list.

By changing the service agreement and increasing subsidies (especially the costs per case), the Government can provide the service units with more incentives and resources to enhance their service quality and respond to social and emotional needs of the elderly. The Government may also set and upload on its homepage the standard for each service. Only then will the aged and their family members have a better understanding of the services to be received.

Recommendation 5: Plan for Manpower Increase

Increase the Manpower of Formal Care Workers
In the present home care services, the ratio of professional staff (i.e., social workers, nurses, physiotherapists and occupational therapists) and non-professional staff (i.e., personal care workers and care assistants) is 1:2, while the ratio in day care centres is 1:3. In order to implement our proposed increase in service quotas, additional 395 professionals and 1,071 non-professionals are required. It is recommended that the Government should review the supply of manpower (especially care professionals), and provide training accordingly.

Mobilize Informal Manpower
In terms of increasing non-professional manpower, the Government and subsidized bodies should consider ways through which informal manpower are drawn into the care industry. In fact, nearly 97,000 people, who were not in any job for the last three months at the time of survey, are willing to take up a job if a chance arises. Most of them are middle-aged women, ‘young old’ and students. Half of them are willing to work 40 hours per week, with a substantial number looking only for part-time jobs. Hence flexible hours should be allowed for the subsidized organizations to tap into this pool of human resources.

Develop ‘District-based’ Services
Many persons from the informal manpower sources also expect to work near their homes. It is recommended that the provision of care services should be developed on district basis, drawing upon the human resources to serve the elderly who live in the same districts as they do. In this regard, district elderly community centres can be developed into recruitment centres, in addition to their pre-existing liaison role among service units. Interested people are registered with these centres to assist service organizations that have operation in the same districts.

Recommendation 6: Allocate Space for Operators

To implement our proposed increase in service quotas, the Government has to allocate, by 2019-20, additional 16,000 square meters of space for operators of day care centres, which is only 40% of the space required for the expansion of residential care. The space required for the expansion of home care services is even much less. To meet their space requirement, the Government may consider: 1) to allocate the unoccupied units on the ground floor of public housing for the use by community care operators; 2) to subsidize the operators either to rent the unoccupied space in private nursing homes, or to purchase meal services from the latter, so that residual space is fully utilized; and 3) to include the space requirement into the Schedules of Accommodation (Elderly Services) and so into the government planning.

Recommendation 7: Promote Community Care Services

Unawareness of other choices is one of the main reasons for the use of residential care. It is necessary for the Social Welfare Department to consider the ways to promote community care services. The promotion can be done through cooperation with the Home Affairs Department, drawing on the latter’s community networks (e.g., mutual aid organizations, residents’ associations and owners’ corporations) to get the messages across. The Social Welfare Department may also consider earmarking resources for district elderly community centres to have extra social worker head counts, so that outreach work can be further developed.

Recommendation 8: Promote Contact between the Young and Old

With the trend towards smaller-sized families, the youth will have less opportunities to have close contact with the aged. the Government (especially the Education Bureau) should, in cooperation with schools, organize more activities through which the youth will have increased and closer contact with the elderly. This is conducive to fostering a friendly environment for the elderly. In particular, the Government may encourage non-government organizations wo cooperate with secondary schools on the ‘Other Learning Experiences’ (OLE) in the school curriculum.

Conclusion

The manners in which the elderly are treated is emblematic of a civilized society. They have spent decades of contribution to the society, and their expectation for aging in place and in community with which they are familiar is not asking too much. Any conscientious and responsible policy-maker has to make positive response to the principle of aging in place.